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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: IFd 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ZX 777 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NameZZI I/8's . <br /> Phone <br /> Address CitS' C�6d/� � <br /> y , <br /> Contractor's Name ALicense �� Qf)Phone � <br /> TYPE OF WORK (Cheek) : NEW+'WELL. /.. /j_DEEPEN.•/, RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / ..PUMP REPAIR /)�7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE -'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 5 . <br /> Industrial Cable Tool Dia, of<Well Excavation.' <br /> Domestic/private Drilled Dia, of'Well Casing ^' <br /> Domestic/public Driven Gauge `of Casing '. I <br /> Irrigation Gravel Pack Depth of Grout Seal ._ NJ <br /> Cathodic Protection Rotary Type of ~Grout `,rt a -� <br /> Disposal Other Otherilnformation <br /> Geophysical Surface'_Seal Installed By: <br /> PUMP INSTALLATION: Contractor ; r <br /> Type of Pump"'. ,f H.P. <br /> t t <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP .REPAIR: W State W r Done04J <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and-'notify them before putting the well- in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR-A GROUT INSPECTION <br /> PRIOR TO GROUTXNG AND A F AL .I SPECTION. 7 <br /> SIGNED TITLE dA <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �tj Wim. DATE <br /> E H 1426 ` -Rev. 1-74- 1/77. 2M <br />